Michael R. Jaff, DO, FACP, FACC, Medical Director of the MGH Vascular Center, received his BS from Dickinson College, in Carlisle, PA; DO from Kirksville College of Osteopathic Medicine in Kirksville, MO; residency training and fellowship in vascular medicine at the Cleveland Clinic Foundation.
He was instrumental in creating and shaping the Vascular Center at Mass General West in Waltham, and directs the Vascular Diagnostic Laboratory. An Associate Professor of Medicine at Harvard Medical School, Dr. Jaff also directs the Vascular Ultrasound Core Laboratory - one of the largest clinical research vascular labs in the world. His research focus includes novel therapies for peripheral vascular disease, as well as device and clinical trial development. He is particularly interested in the safety and durability of endovascular devices (predominantly stents) used as therapy for peripheral vascular diseases.
Dr. Jaff serves on the American College of Radiology Expert Consensus Panel on Cardiovascular Imaging; is past president of the Society for Vascular Medicine; treasurer of the Intersocietal Commission for the Accreditation of Vascular Laboratories; and founder of the American Board of Vascular Medicine. Dr. Jaff received the first designation of "Master" of the Society for Vascular Medicine in June 2007.
"As director of the MGH Vascular Center," says Dr. Jaff, "my role is to push forward the initiatives of the Vascular Center and provide the highest level of truly integrated multidisciplinary vascular disease care in the US."
About a year ago, a man in his 70s was referred to the Vascular Center. He had a series of complex medical problems and communication among his physicians was suboptimal. He had one problem that was directed in "tunnel-vision focus" by one specialist who said, "I don't deal with that problem, so I'll send you to someone else," and so on down the line. He ended up falling through the cracks and was left in a very difficult situation. So when he came to see me, it was clear that it was an extraordinarily challenging case with a lot of history. And I was able to bring into play, at no effort to him - neurology, interventional neuroradiology, radiology, and vascular surgery.
The Vascular team spent time together going over all the pertinent images, and coming up with a plan that offered the patient the best options under difficult circumstances. And that's what the Vascular Center does. It allows the patient to get the expertise of multiple disciplines without having to lift a finger. The patient has one champion who is their quarterback. The bottom line is that patients don't have to drive to five different appointments and ten different places for tests.
We've also created a set of standards for professional credentialing that every doctor in the Vascular Center has to meet. A vascular surgeon, interventional radiologist, cardiologist, etc. all have to follow the same rules and meet the same credentialing guidelines. So, physicians, who perform carotid artery stents, all have to have the same number of cases under their belts. It doesn't matter what the specialty background. Patients can be assured that whomever is assigned to them from the Vascular Center, that physician will have met the highest standards - higher than standard guidelines around the country.
Richard Cambria, MD, Chief, Division of Vascular and Endovascular Surgery, and Professor of Surgery at Harvard Medical School, received his MD degree at the College of Physicians and Surgeons at Columbia University in New York, and residency training and fellowship at MGH, the latter in vascular surgery.
His accomplishments in the field of vascular surgery include authoring or co-authoring more than 150 scientific papers and 50 textbook chapters. He is Co-Director of the MGH Thoracic Aortic Center - a multi-disciplinary group with extensive experience in managing the spectrum of thoracic aortic pathology, and Program Director for the Vascular Fellowship. He also chairs the Vascular Center's Clinical Operations Committee.
Dr. Cambria has extensive experience in complex aortic reconstruction, especially thoracoabdominal aneurysms and is widely recognized as an authority in this area. His research includes thoracoabdominal reconstruction, risk stratification in vascular surgery, spinal cord protection, and renovascular disease.
"As the Chief of Vascular and Endovascular Surgery at MGH, I am one of the leaders of the Vascular Center," says Dr. Cambria. "Our Division continues as one of the cornerstones of the Vascular Center."
The outpatient facility in Waltham offers patients added convenience and speed in scheduling vascular appointments including diagnostic imaging studies. Patients can take advantage of our onsite noninvasive vascular laboratory, and next-door access to MRIs and CAT scans. The multiple specialists that see patients means that we can schedule several different disciplines on the same day, and that's a great convenience to patients.
The outpatient facility in Waltham also offers certain patients - depending on their geography - a suburban location and convenience of avoiding a trip into Boston.
The Vascular Center is very much the product of collaboration. In my own work, for example, the specialists that I use in particular would be neurology stroke doctors because I see many patients with carotid artery disease.
What is most exciting about the Vascular Center? For me as a clinician, it serves as a vehicle and forum, in which to interact with other colleagues working on complex cases. And two, since I have an enormous and busy practice, the ability to have another locale, another vascular lab, and another imaging suite is great. It enables me to handle the extra load and accommodate my patients more efficiently.
Mary Deborah Hines, Nurse Practitioner, received her Master of Science in Nursing at Boston College; Bachelor of Science in Nursing from Atlantic Union College, in South Lancaster, MA, where she graduated Cum Laude; and certificate at Lawrence Memorial Hospital School of Nursing, in Medford, MA, where she graduated with honors.
Ms. Hines has written for publications such as Brief Treatment and Crisis Intervention, and Nurse Hearts and Hands. Additionally, she has served on the Winchester Hospital Ethics Committee and Kenneth B. Schwartz Center Planning Committee, and participated in the Kenneth B. Schwartz Rounds as presenter.
I see patients with all types of vascular disease. A perfect example was one of our first patients, who was having severe leg discomfort when he walked. One of the things we had to sort out was whether he had narrowing of the arteries in the leg- a classic symptom of a vascular disease - or something else. But after we saw him and took a comprehensive history, we realized that he had other vascular issues that turned out to have greater urgency. We discovered that he had significant coronary disease, adult onset diabetes, and small stroke. Those became a priority. But we followed up on his leg pain when he was out of danger, and it was safe to do so.
As a nurse practitioner, I'd like to think that I make vascular patients accessible to providers who can sort out what they need. I follow up so patients get their blood work or vascular tests done, and come back for scheduled appointments. There's also a great deal of teaching involved, and it's one of the things I love best. When patients initially see a specialist, or receive a diagnosis, they may need additional support. In fact, some studies show that patients only absorb about 50% of what they're told at the time of the provider's visit. Often I'll say to them, "When you get home, if you can't remember what you were told at your visit, please call me and we'll go over it." Many times we'll review the instructions, what patients need do to in preparation for tests, or what their test results mean.
I've also come to appreciate the complexity of our patients and the longitudinal relationships I have with them. It's not episodic care - where they come in once and get fixed. It requires followup over time. So, you develop a relationship and partner with patients in order to comprehend how they can take better care of themselves. It's definitely a collaborative model of practice, and many patients view their relationship with us as a personal one. Healthcare is always a personal experience. Sometimes, they even call to tell me about the birth of a new grandchild.
Kenneth Rosenfield, MD, Section Head for Vascular Medicine and Intervention in the Division of Cardiology, received his BA from Dartmouth College, MD from the University of Massachusetts, and residency training at Kaiser San Francisco, where he served as chief resident. Dr. Rosenfield also completed a cardiology fellowship at New England Medical Center and interventional cardiology and vascular medicine fellowship at St. Elizabeth's Medical Center of Boston.
Dr. Rosenfield is an expert in managing and treating both coronary artery disease and vascular disease outside of the heart. He will sometimes treat both heart and leg or kidney blockages at the same time, if appropriate. Over the past 12 years, Dr. Rosenfield has played a key role in developing and perfecting the technique of carotid artery stenting, and is locally and nationally prominent in this field. Other areas of expertise, for which he is recognized as a national expert, include renal, mesenteric, and lower extremity stenting; intravascular ultrasound, excimer laser angioplasty, and thrombolytic therapy.
Dr. Rosenfield is the author of many books and journal articles on carotid and peripheral arterial disease. He has also either led or served as a member on several national task forces committed to: creating guidelines for managing peripheral vascular disease (PVD), establishing standards for physician training and credentialing, and developing protocols for carotid and cerebrovascular imaging and intervention.
"The Vascular Center," says Rosenfield, "is a unique entity where seven or more medical disciplines have agreed to make patient care their first priority. In so doing, we put aside some of our specialty differences and opinions in order to access each other's expertise, clinical knowledge, and technical skills -- and package that in a way that optimizes care for the patient with vascular disease. Whether a patient sees a neurologist, cardiologist, vascular medicine doc, vascular surgeon or neurosurgeon for carotid artery disease, she or he will have access to all of the knowledge and expertise encompassed within the MGH Vascular Center.
Recently, a woman in her 80's with an abdominal aortic aneurysm was referred to me. She had been seen at a community hospital, and had been evaluated by a vascular surgeon. He wanted to operate immediately. Her son fortunately sensed that there were other alternatives. When I saw her, it was immediately obvious that there were other ways to look at management of her aneurysm. She is an elderly patient whose aortic aneurysm is on the borderline in terms of enlargement. She has heart disease, carotid artery disease, and narrowing of the renal arteries - important factors which hadn't been adequately factored in. Her renal insufficiency also put her at high-risk. Finally, there were the important issues of her life-style and life expectancy. We went over each aspect of her health status and discussed the impact on her longevity, and especially her quality of life. She was evaluated by one of our surgeons, who has done endovascular repair of aneurysms in a large number of patients. We also arranged for her to be seen by a kidney and lung specialist.
"Should we perform surgery or endovascular stent repair?" we asked. At the end of the day, we decided that the best thing for this particular woman was to be conservative in managing her case. As a team, we recommended against any invasive therapy, and instead suggested that we watch her closely to evaluate for any further enlargement of the aneurysm. I will quarterback this, and see her again in 6 months' time. She is very happy with the outcome, and satisfied that she has had the best minds from multiple disciplines working together to optimize the approach to her care.
Jacqueline G. Somerville RN, PhDc, Associate Chief Nurse at Massachusetts General Hospital, is a doctoral candidate in Nursing at Boston, with anticipated completion in 2008. She received her BS at Boston College and MS in Nursing Administration at Boston University.
She is currently a member of the American Organization of Nurse Executives, Massachusetts Organization of Nurse Executives, Sigma Theta Tau, and the American Nurses Association.
As the Associate Chief Nurse, she has been involved in the Vascular Center from the very beginning - planning its design, implementation and opening. "In talking about the Center, and the desire to redesign the healthcare center for the 21st century, one of the things we envisioned was comprehensive care for patients," she said.
The unique and really exciting thing about the Vascular Center is that no longer must the patient, who has a potential risk for stroke, determine whether to see a vascular medicine doc, vascular surgeon, or cardiac interventionalist. Patients can come to one place, depending on symptomatology and diagnosis, and be seen by multiple specialists. Then you sit down, and in consultation with the family, determine what is the best plan based on everyone's input. It is a much more family-friendly way to sort through what is a maze or complex system.
In Boston, we have a virtual center. In other words, all seven specialties have come together in collaboration. When a vascular surgeon sees a patient, he may consult with his peers in other specialties to determine who is the best person to see that patient. We are indeed very fortunate to have a collaborative community that comes together around patients with vascular disease - across what had been traditional silos or departmental lines.
From a nursing perspective, our clinical units are very much specialty based. Now we have the opportunity to have nurses across specialties come together and influence each other's practice and think holistically about the patient. When we think about these patients, it is not as a carotid patient, but truly as a vascular patient. And when we think about resources to help them live with vascular disease, before sending them back into the community, we're now thinking in a much broader way.
Endless Possibilities
Lastly, we have some of the most brilliant and dedicated clinicians caring for vascular patients here at Mass General. Sitting in a room with that much brain power - and thinking about one population of patients - is an unbelievable experience. When you think about research across those specialties, or improving the quality of care, the possibilities are endless.
Stephan Wicky, MD, Section Head of Interventional Vascular Radiology, and Division Head of Cardiovascular Imaging and Intervention, received his MD from the University of Lausanne Medical School, in Switzerland, and residency training in radiology from University Hospital of Lausanne in Switzerland. Dr. Wicky also completed fellowships in Interventional Cardiology at the Hospital in Uppsala, Sweden; Interventional Radiology at University Hospital in Lausanne Switzerland; and Cardiac CT at MGH. He is Assistant Professor of Radiology at Harvard Medical School.
Dr. Wicky's clinical interests include vascular radiology and arterial and venous interventions, as well as research in vascular diseases, CTA, and MRA. He established the Interventional Radiology (IR) Clinic, where patients can be evaluated before special interventional vascular procedures, and followed up longitudinally. As a result of his leadership, vascular ultrasound Doppler protocols have been updated, and the level of these examinations has improved. Patients suffering from peripheral vascular disease (PAD) can now be evaluated in the IR Clinic, and efficiently tested and imaged using ultrasound radiology during the same visit.
The Vascular Center offers one-stop shopping where all seven specialities come together. Sometimes a patient, who is seeing us for the first time, has peripheral vascular disease, or cramping in the legs. But we may also suspect other associated conditions - either in the coronary or carotids. So, we consult with colleagues in cardiology or neurology in order to provide optimal patient care. This is very good. In focusing on only one manifestation of atherosclerosis, such as PAD, you may miss a life-threatening situation or dramatic outcome when performing a procedure. Doing a baseline vascular assessment on all three is one of the great advantages of the Vascular Center.
Currently I am following a patient with a cardiac surgeon, because he may also benefit from heart surgery. The other group of patients we are treating has renal vascular hypertension. I work with three or four renal associates in order to define with them the most appropriate time to perform the procedure. In many patients, medical therapy is key, and by having other disciplines involved, we offer a full spectrum of patient care.
What is so exciting about the Vascular Center is not only patient care, but the whole process. At regular Q&A sessions and monthly multidisciplinary meetings, we discuss some of the more complex cases. Our physicians commit to a high level of credentialing and care and that is of great value. Sometimes we discuss the procedure itself. For instance, "Would someone do it differently?" we ask. We also coordinate all the clinical trials on new devices and new drugs, and help patients enroll in these. Because we communicate and share patients, someone might say, "Maybe that patient could benefit from a trial instead of a stent. Why don't we try this for six weeks and see if he improves." It's a very open-minded and a sharing process.
Laura Haley, MHP, PA-C, received her BS degree in biology from Providence College in Rhode Island, and Physician Assistant certificate from Northeastern University in Boston. She was elected to Phi Kappa Phi Honor Society and graduated Cum Laude.
Ms. Haley works under the direction of three attending cardiologists and vascular specialists at MGH. She evaluates patients prior and following their angioplasty procedures and diagnostic angiograms, determines whether they are eligible for specific research protocols such as carotid angioplasty and stent feasibility trials, and recommends appropriate diagnostic studies and patient management strategies.
She has contributed to review journals such as The Lancet, Journal of American College of Cardiology, Circulation, and Frontiers in Interventional Cardiology.
As Physician Assistant, I see patients who have problems, not only with their legs, but with their kidneys, carotid arteries, or venous system. Because we have this Center, and close proximity to specialists in each field, we can contact them instantly via e-mail, page or phone and get an answer for the patient then and there. I have one particular patient, with whom I am working very closely. I referred her to Dr. Robert Schainfeld, a vascular specialist at the Waltham Center. Her initial complaint was that of claudication (pain in the calf or thigh muscle). But as it turns out, she also had a serious venous condition. I consulted with Dr. Schainfeld and the patient is going to end up having venous surgery.
I also counsel patients about the risk factors that led to their condition, and how they might modify them. The approach you use is really important. Studies have shown that if providers don't even bring up the subject- smoking cessation for example - that patients are not even going to think about it. In fact, it's probably our main focus. We deal with the disease process of course. But the patient has to understand where it comes from, and what caused it to begin with. I don't think that any one of us here takes that lightly, and no one ever leaves the office without that counseling.
One of the amazing things about MGH is the technology. We have, at our fingertips, the ability to review an MRA, scan, or vascular study. Other institutions do not necessarily have that capability. We also have the top people in the country working on vascular disease. That is incredibly comforting to me as a practitioner, and to our patients as well. Vascular medicine is such a prevalent condition - with a high mortality and morbidity rate associated with it. It's finally coming to the forefront as a serous entity, and I think in that context, the group we have here is only going to get bigger and better.